This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Federally funded surveys of human papillomavirus (HPV) vaccine uptake are important for pinpointing geographically based health disparities. Although national and state level data are available, local (ie, county and postal code level) data are not due to small sample sizes, confidentiality concerns, and cost. Local level HPV vaccine uptake data may be feasible to obtain by targeting specific geographic areas through social media advertising and recruitment strategies, in combination with online surveys.
Our goal was to use Facebook-based recruitment and online surveys to estimate local variation in HPV vaccine uptake among young men and women in Minnesota.
From November 2012 to January 2013, men and women were recruited via a targeted Facebook advertisement campaign to complete an online survey about HPV vaccination practices. The Facebook advertisements were targeted to recruit men and women by location (25 mile radius of Minneapolis, Minnesota, United States), age (18-30 years), and language (English).
Of the 2079 men and women who responded to the Facebook advertisements and visited the study website, 1003 (48.2%) enrolled in the study and completed the survey. The average advertising cost per completed survey was US $1.36. Among those who reported their postal code, 90.6% (881/972) of the participants lived within the previously defined geographic study area. Receipt of 1 dose or more of HPV vaccine was reported by 65.6% women (351/535), and 13.0% (45/347) of men. These results differ from previously reported Minnesota state level estimates (53.8% for young women and 20.8% for young men) and from national estimates (34.5% for women and 2.3% for men).
This study shows that recruiting a representative sample of young men and women based on county and postal code location to complete a survey on HPV vaccination uptake via the Internet is a cost-effective and feasible strategy. This study also highlights the need for local estimates to assess the variation in HPV vaccine uptake, as these estimates differ considerably from those obtained using survey data that are aggregated to the state or federal level.
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States [
Two vaccinations against HPV infection are currently licensed in the United States. The vaccinations were originally licensed for use in girls, but as of October 2011, the Advisory Committee on Immunization Practices extended their recommendation of the quadrivalent vaccine to include both boys and girls aged 11 or 12 years old [
Previous research on HPV vaccine coverage has used publicly available data from five national health surveys (National Survey of Family Growth, National Immunization Survey [NIS]-Teen, National Health and Nutrition Examination Survey, National Health Interview Survey [NHIS], and the Behavioral Risk Factor Surveillance System) [
The Internet provides a unique point of contact to reach young adults for health research. Several studies have demonstrated that Internet-based research can be used to elicit high response rates at a fraction of the cost of traditional recruitment methods [
The objective of this study was to estimate HPV vaccination practices among a local population of young adult men and women in the United States using an Internet-based recruitment strategy.
Men and women from Minnesota were surveyed about their HPV vaccination practices via the Internet from November 21, 2012, through January 31, 2013. Participants were English-speaking, aged 18-30 years, had a Facebook account, and resided in the greater Twin Cities Metropolitan Area (ie, within 25 miles of downtown Minneapolis, MN). This age range was used to target men and women who were eligible to receive the HPV vaccine, participate in cervical cancer screening (women), and able to provide informed consent. The Twin Cities Metropolitan Area was selected due to the variation of HPV-related cancer incidence rates exhibited in this area during the past 15 years, the high concentration of colleges and universities, and the large population of 18-30 year olds residing in this area [
Participants were recruited online via Facebook advertisements (
The Facebook Ads Manager was used to track the total number of impressions (each time an advertisement was displayed), the number of times an ad was clicked, the average cost-per-click, and the number of people reached (ie, the number of Facebook users that had an opportunity to view one of the study advertisements). Google Analytics software was used to tabulate the total number of visits, the unique visits, the average duration of visits, and the bounce rate (the percentage of visitors that visit a website and leave the site without further browsing) of the study website.
Examples of Facebook advertisements.
Participants who clicked on a Facebook advertisement were directed to a secured study website and were provided with information regarding the purpose of our study. Participants provided informed consent by clicking on a button that directed them to the study questionnaire. After providing consent, study participants were immediately asked to self-report their age and state of residence. Participants who did not meet the age criteria or who reported that they did not live in Minnesota were considered ineligible and were disqualified from answering the remainder of the questionnaire. Study participants who met the eligibility criteria were also asked to self-report their gender, postal code of their home address, race/ethnicity, highest level of education attained, attendance at religious services, political preferences, sexual orientation, their awareness of HPV, and whether or not they had received the HPV vaccine. Conditional upon participants’ responses, skip logic patterns (ie, participants skip over survey questions that, based on their answers to other questions, do not need to be filled out) were implemented in order to ask applicable follow-up questions regarding the number of shots received, the vaccine type (quadrivalent/bivalent), and reason(s) for not having received the vaccination, as well as future vaccination intentions. Female participants were also asked a series of adaptive questions about past cervical cancer screening. The survey questions regarding HPV vaccination and cancer screening that we used in this study were questions used in the five national surveys mentioned above, in order to facilitate comparisons between studies. Participants were not required to answer every question and could exit the survey at any time. Computer Internet Protocol (IP) addresses were tracked, and multiple entries from the same IP address were not accepted. Survey responses that contained repeated email addresses across multiple survey attempts (n=86) were not accepted. Additionally, 8 surveys that were only partially completed (ie, the participant withdrew) were not included in the analyses. The survey was anonymous and was administered using the online survey assessment tool SurveyMonkey. Eligible respondents who provided informed consent and completed the online survey were emailed an electronic gift card in the amount of US $20 for Target.
Of the 2079 men and women who were recruited via Facebook and visited the study website, 1003 (48.24%) enrolled in the study and completed the survey. Targeted advertising within Facebook based on geographic and age criteria limited the number of ineligible participants (4.4% of all survey attempts) who attempted to access the survey. In total, 86 survey attempts (7.5% of all survey attempts) were identified as duplicate surveys, indicating that an individual attempted to complete the survey more than once (
The recruitment target area for this study was a 25-mile radius from downtown Minneapolis, Minnesota. Of the 972 participants who reported their postal code, 881 (90.6%) lived within the recruitment study area.
A total of 1003 participants (557 women and 446 men) completed the online survey. Characteristics of the study population are presented in
Selected study participant characteristics compared to US Census estimates for Minneapolis and St. Paul, Minnesota.a
|
Study participants | Census data | |||
Men, n=446 | Women, n=557 | Total, N=1003 | Minneapolis/St. Paul, % | ||
Mean age, years | 23 | 23 | 23 | 18 to 34 | |
|
|||||
|
White | 384 (86.3) | 457 (82.3) | 841 (84.10) | 79.3 |
|
Black | 17 (3.8) | 33 (5.9) | 50 (5.00) | 9.1 |
|
Asian | 30 (6.7) | 30 (5.4) | 60 (6.00) | 8.1 |
|
American Indian or Alaska native | 2 (0.4) | 7 (1.3) | 9 (0.90) | 0.8 |
|
Native Hawaiian or Pacific Islander | 1 (0.2) | 3 (0.5) | 4 (0.40) | 0.03 |
|
Other | 11 (2.5) | 25 (4.5) | 36 (3.60) | 2.6 |
|
|||||
|
Hispanic | 15 (3.4) | 19 (3.4) | 34 (3.42) | 5.2 |
|
Non-Hispanic | 427 (96.6) | 533 (96.6) | 960 (96.58) | 94.8 |
|
|||||
|
<High school | 2 (0.4) | 0 (0.0) | 2 (0.20) | 1.9 |
|
Some high school | 6 (1.3) | 8 (1.4) | 14 (1.40) | 8.0 |
|
High school graduate | 36 (8.1) | 36 (6.5) | 72 (7.19) | 21.9 |
|
Some college/tech. school | 190 (42.7) | 209 (37.6) | 399 (39.86) | 36.3 |
|
College graduate | 167 (37.5) | 237 (42.6) | 404 (40.36) | 25.1 |
|
Graduate school | 44 (9.9) | 66 (11.9) | 110 (10.99) | 6.8 |
aData are 5-year estimates for 18-34 year-olds in the Minneapolis-St. Paul Metropolitan Area as described in the 2006-2010 American Community Survey of the United States Census Bureau.
Selected survey responses regarding vaccination against human papillomavirus.
Survey question | Men (n=446) | Women (n=557) | Total (N=1003) | |
|
|
n (%) | n (%) | n (%) |
|
||||
|
Yes | 409 (93.0) | 536 (96.8) | 945 (95.07) |
|
No | 31 (7.0) | 18 (3.2) | 49 (4.93) |
|
||||
|
Yes | 361 (82.4) | 535 (96.6) | 896 (90.32) |
|
No | 77 (17.6) | 19 (3.4) | 96 (9.68) |
|
||||
|
Yes | 45 (13.0) | 351 (66.5) | 396 (45.26) |
|
No | 302 (87.0) | 177 (33.5) | 479 (54.74) |
|
||||
|
1 shot | 11 (24.4) | 31 (8.8) | 42 (10.61) |
|
2 shots | 14 (3.9) | 38 (10.8) | 52 (13.13) |
|
3 shots (complete vaccine series) | 10 (22.2) | 263 (74.9) | 273 (68.94) |
|
Don’t know | 10 (22.2) | 19 (5.4) | 29 (7.32) |
|
||||
|
Very likely | 7 (2.3) | 13 (7.3) | 20 (4.18) |
|
Somewhat likely | 26 (8.6) | 30 (16.9) | 56 (11.69) |
|
Not too likely | 75 (24.8) | 47 (26.6) | 122 (25.47) |
|
Not likely at all | 173 (57.3) | 84 (47.5) | 257 (53.65) |
|
Not sure/don’t know | 21 (7.0) | 3 (1.7) | 24 (5.01) |
|
||||
|
Not needed or necessary | 140 (52.4) | 40 (31.3) | 180 (45.57) |
|
Not sexually active | 33 (12.4) | 23 (18.0) | 56 (14.18) |
|
Knowledgeb | 25 (9.4) | 10 (7.8) | 35 (8.86) |
|
Safety concerns/side effects | 9 (3.4) | 22 (17.2) | 31 (7.85) |
|
Costs | 13 (4.9) | 14 (10.9) | 27 (6.84) |
|
Already have HPV | 19 (7.1) | 5 (3.9) | 24 (6.08) |
|
Monogamous | 8 (3.0) | 6 (4.7) | 14 (3.54) |
|
Otherc | 6 (2.2) | 6 (4.7) | 12 (3.04) |
|
Not for men | 11 (4.1) | 0 (0.0) | 11 (2.78) |
|
Too old | 3 (1.1) | 2 (1.6) | 5 (1.27) |
aResponses presented are for the 479 individuals who reported not having been vaccinated against HPV.
bDon’t know about HPV or HPV vaccine.
cResponses included “fear of needles”, “too busy/no time”, “don’t use vaccines”, or “already sexually active”.
Recruitment summary flowchart.
Map of the recruitment target area and the number of completed surveys by ZIP code.
In this study, we found that recruiting a locally representative sample of young adults via the Internet to participate in a survey about HPV vaccination was cost-effective and efficient. Approximately half of the 2079 individuals that clicked on an advertisement and visited our study website participated and completed our survey at an estimated advertising cost of US $1.36 per enrolled participant. Consistent with other studies, this study found that using the Internet, and in particular social media sites such as Facebook, is successful for recruiting and engaging young adults and hard-to-reach populations for health research [
Notably, the characteristics of our study population were similar to those of the source population. An estimated 90% of Internet users aged 18-29 years in the United States access social media sites (71% accessed Facebook) in 2013; thus, this finding is likely attributable to the wide reach of social media recruitment [
In this study, we were also able to collect detailed HPV vaccination data, including participation in screening (for women) and potential barriers to receiving these services among a representative sample of men and women in a defined local geographic area. National surveys including the Behavioral Risk Factor Surveillance System, the NHIS, and the NIS-Teen do not simultaneously assess these factors within the same respondents in their populations. Additionally, these (and other) national surveys aggregate or suppress responses due to participant identification concerns and consequentially local variation and patterns may be obscured. However, HPV vaccine policies, availability, costs, financial assistance, and education materials vary widely across states or even more defined geographic regions [
Of note, the proportion of all adults in this study who had been vaccinated against HPV (ie, received at least one dose of an HPV vaccine) was 45.3% (66.5% for women and 13.0% for men). These estimates are much higher than the HPV vaccine coverage estimates from the 2012 NHIS for women (34.5%) and men (2.3%) aged 19-26 years (
HPV vaccine coverage estimates for men and women in the United States from three surveys.
|
HPV vaccine coverage (≥1 dose) | |||
|
Men | Women | ||
Survey | % | 95% CIa | % | 95% CI |
SMASHb | 13.0 | 9.4-16.5 | 65.6 | 61.6-69.6 |
NHIS | 2.3 | 1.6-3.4 | 34.5 | 31.7-37.3 |
NIS–Teen | 20.8 | 19.3-22.3 | 53.8 | 51.9-55.7 |
a95% confidence interval.
bData are from the Survey of Minnesotans About Screening and HPV, 2013.
Limitations include the fact that the survey responses were self-reported by persons over the Internet and may be subject to under or overreporting. However, other Internet-based studies have shown increased self-disclosure and reporting with online surveys, which may reduce potential response biases (eg, interviewer bias or social desirability) [
To our knowledge, this is the first study to estimate local level vaccination uptake among young men in the United States. Understanding the local variation and patterns of HPV vaccination of young men could serve to identify areas where HPV infection-related health disparities may continue if neglected. In particular, the online survey also allowed us to collect data on sexual orientation, which in turn would allow us to understand whether men who have sex with men, who are at high risk of HPV-related anal cancer, are receiving the vaccine and to also determine whether reductions in the overall risk of HPV infection will affect transmission to females [
The results from this study suggest that more detailed and local assessments of HPV vaccine uptake are necessary as estimates vary greatly from national surveys. In addition, recruiting young adults via the Internet is efficient, cost-effective, and can produce a representative sample of the target population. Future work is needed to understand the pattern of HPV vaccine uptake at local levels in order to identify areas that may be best served by vaccine programs.
human papillomavirus
Internet Protocol
National Health Interview Survey
National Immunization Survey
This study was supported by the JB Hawley Student Research Award from the University of Minnesota School of Public Health and by the Minnesota Medical Foundation through Grant 4120-9227-12.
EN and SK conceived and designed the study. EN conducted the data collection and drafted the manuscript. JH, JP, and JMO assisted in the survey design, supervised the statistical analysis, and assisted in reviewing/revising the manuscript. SK provided contributions to the concept and analytical approach for the article and oversaw the analysis, interpretation, and reviewing/revising of the manuscript.
None declared.